Heavy Menstrual Heavy Menstrual BleedingBleeding

Heavy Menstrual Bleeding Heavy Menstrual Bleeding

Also called menorrhagiaAlso called menorrhagia Excessive menstrual bleeding which Excessive menstrual bleeding which

interferes with a woman’s physical, social, interferes with a woman’s physical, social, emotional or material quality of lifeemotional or material quality of life

Causes of Heavy Menstrual Causes of Heavy Menstrual BleedingBleeding

Bleeding disorders – rareBleeding disorders – rare Endometrial Hyperplasia – early teens, 40s, Endometrial Hyperplasia – early teens, 40s,

throughout reproductive life in women with throughout reproductive life in women with polycystic ovarian syndromepolycystic ovarian syndrome

FibroidsFibroids AdenmyosisAdenmyosis Endometrial PolypsEndometrial Polyps Endometrial CancerEndometrial Cancer Dysfunctional uterine bleedingDysfunctional uterine bleeding

Age-related incidence of Cancer of Age-related incidence of Cancer of the Endometriumthe Endometrium

HistoryHistory

Duration of problemDuration of problem Cycle, duration of bleeding, intermenstrual Cycle, duration of bleeding, intermenstrual

bleedingbleeding Impact on lifeImpact on life Type of protection used, how often Type of protection used, how often

changed, flooding, clotschanged, flooding, clots Co-existing symptoms e.g. pain, Co-existing symptoms e.g. pain,

symptoms of anaemiasymptoms of anaemia

ExaminationExamination

General –signs of anaemia, General –signs of anaemia, hypothyroidism,obesity, acne, hirsutismhypothyroidism,obesity, acne, hirsutism

Abdominal examination – is the uterus Abdominal examination – is the uterus palpable?palpable?

Bimanual vaginal examination where Bimanual vaginal examination where appropriate, size of uterus, tenderness, appropriate, size of uterus, tenderness, mobility mobility

Investigations 1Investigations 1

Screen for bleeding disorders such as Von Screen for bleeding disorders such as Von Willebrand disease in women who have Willebrand disease in women who have had heavy menses since menarche or with had heavy menses since menarche or with personal of family history to suggest a personal of family history to suggest a problemproblem

Thyroid disease if history or physical exam Thyroid disease if history or physical exam suggestivesuggestive

No evidence to support hormonal No evidence to support hormonal investigations investigations

Investigations 2 -Indications for Investigations 2 -Indications for Endometrial BiopsyEndometrial Biopsy

Co-existent intermenstrual bleedingCo-existent intermenstrual bleeding Heavy bleeding, prolonged bleeding in Heavy bleeding, prolonged bleeding in

women over 40, no response to medical women over 40, no response to medical treatment treatment

Look for endometrial hyperplasia or Look for endometrial hyperplasia or malignancymalignancy

Investigations 3 -UltrasoundInvestigations 3 -Ultrasound

Uterus palpable abdominallyUterus palpable abdominally Uterus enlarged on bimanual examinationUterus enlarged on bimanual examination Medical treatment has failedMedical treatment has failed Transvaginal U.S. usually more helpfulTransvaginal U.S. usually more helpful Fibroids, endometrial polyps, adenomyosis Fibroids, endometrial polyps, adenomyosis

Investigations 4 -Indications for Investigations 4 -Indications for HysteroscopyHysteroscopy

To provide additional information on To provide additional information on abnormality already inidicated on TVUS abnormality already inidicated on TVUS e.g. exact location of a polyp or fibroid.e.g. exact location of a polyp or fibroid.

Possible Treatments for Heavy Possible Treatments for Heavy Menstrual BleedingMenstrual Bleeding

Tranexamic Acid, NSAIDsTranexamic Acid, NSAIDs Combined pill, oral norethisterone day 6-Combined pill, oral norethisterone day 6-

26, injectable progestagens, levo-26, injectable progestagens, levo-norgesterol device,GnRh Analoguenorgesterol device,GnRh Analogue

Fibroid embolisation, endometrial ablationFibroid embolisation, endometrial ablation Myomectomy.vaginal hysterectomy, Myomectomy.vaginal hysterectomy,

abdominal hysterectomyabdominal hysterectomy

Hysterectomy for HMBHysterectomy for HMB

other treatment options have failed, are other treatment options have failed, are contraindicated or are declined by the contraindicated or are declined by the womanwoman

there is a wish for amenorrhoea there is a wish for amenorrhoea the woman (who has been fully informed) the woman (who has been fully informed)

requests it requests it the woman no longer wishes to retain her the woman no longer wishes to retain her

uterus and fertility.uterus and fertility.

Discussions prior to HysterectomyDiscussions prior to Hysterectomy

ComplcationsComplcations Loss of fertilityLoss of fertility Sexual feelingsSexual feelings Bladder functionBladder function Woman’s expectationsWoman’s expectations Need for further surgeryNeed for further surgery Pros and cons of oophorectomy Pros and cons of oophorectomy

GnRH AnalogueGnRH Analogue

Prior to surgeryPrior to surgery When all other treatments are When all other treatments are

contraindatedcontraindated If used for over 6 months, then add-back If used for over 6 months, then add-back

HRT should be addedHRT should be added

Endometrial AblationEndometrial Ablation

Where medical treatments have failed, Where medical treatments have failed, HMB is affecting quality of life, in a woman HMB is affecting quality of life, in a woman who does not wish to conceive in the who does not wish to conceive in the futurefuture

Normal uterus or fibroids < 3mm diameterNormal uterus or fibroids < 3mm diameter

Endometrial AblationEndometrial Ablation

Transcervical resection of endometriumTranscervical resection of endometrium Radio-frequency ablationRadio-frequency ablation Thermal balloon ablationThermal balloon ablation Microwave endometrial ablationMicrowave endometrial ablation Free fluid thermal ablationFree fluid thermal ablation

Unwanted Effects of TreatmentUnwanted Effects of TreatmentTreatmentTreatment Potential unwanted outcomes experienced by some women Potential unwanted outcomes experienced by some women (Common: 1 in 100 chance; less (Common: 1 in 100 chance; less

common: 1 in 1000 chance; rare: 1 in 10,000 chance; very rare: 1 in 100,000 chance)common: 1 in 1000 chance; rare: 1 in 10,000 chance; very rare: 1 in 100,000 chance)

Levonorgestrel-releasing Levonorgestrel-releasing intrauterine systemintrauterine system

Common: irregular bleeding that may last for over 6 months; hormone-related problems such as Common: irregular bleeding that may last for over 6 months; hormone-related problems such as breast tenderness, acne or headaches, which, if present, are generally minor and transientbreast tenderness, acne or headaches, which, if present, are generally minor and transient

Less common: amenorrhoea Less common: amenorrhoea Rare: uterine perforation at the time of insertionRare: uterine perforation at the time of insertion

Tranexamic acid Tranexamic acid Less common: Less common: indigestion; diarrhoea; headachesindigestion; diarrhoea; headaches

NNon-steroidal anti-on-steroidal anti-inflammatory drugs inflammatory drugs

Common: Common: indigestion; indigestion; diarrhoeadiarrhoeaRare: Rare: worsening of asthma in sensitive individuals; worsening of asthma in sensitive individuals; peptic ulcers with possible bleeding and peritonitispeptic ulcers with possible bleeding and peritonitis

Unwanted Effects of TreatmentsUnwanted Effects of TreatmentsCCombined oral ombined oral contraceptivescontraceptives

Common:Common: mood changes; headaches; nausea; fluid retention; mood changes; headaches; nausea; fluid retention; breast tendernessbreast tendernessVery rare:Very rare: deep vein thrombosis; stroke; heart attacks deep vein thrombosis; stroke; heart attacks

Oral progestogen Oral progestogen (norethisterone)(norethisterone)

Common: Common: weight gain; bloating; breast tenderness; headaches; acne weight gain; bloating; breast tenderness; headaches; acne (but all are usually minor and (but all are usually minor and transient)transient)Rare: Rare: depressiondepression

Injected progestogenInjected progestogen Common: Common: weight gain; irregular bleeding; weight gain; irregular bleeding; amenorrhoea; amenorrhoea; premenstrual-like syndrome (including premenstrual-like syndrome (including bloating, fluid retention, breast tenderness)bloating, fluid retention, breast tenderness)Less common: small loss of bone mineral density, largely recovered when treatment discontinuedLess common: small loss of bone mineral density, largely recovered when treatment discontinued

Unwanted Effects of TreatmentsUnwanted Effects of TreatmentsGonadotrophin-releasing Gonadotrophin-releasing hormone analoguehormone analogue

Common: Common: menopausal-like symptoms (such as hot flushes, increased sweating, vaginal dryness) menopausal-like symptoms (such as hot flushes, increased sweating, vaginal dryness) Less common:Less common: osteoporosis, particularly trabecular bone with longer than 6-months’ use osteoporosis, particularly trabecular bone with longer than 6-months’ use

Endometrial ablationEndometrial ablation Common: Common: vaginal discharge; increased period pain or cramping (even if no further bleeding); need for vaginal discharge; increased period pain or cramping (even if no further bleeding); need for additional surgery additional surgery Less common: infectionLess common: infectionRare: perforation (but very rare with second generation techniques)Rare: perforation (but very rare with second generation techniques)

Uterine artery Uterine artery embolisationembolisation

Common: Common: persistent vaginal discharge; persistent vaginal discharge; post-embolisation syndrome – pain, nausea, vomiting and post-embolisation syndrome – pain, nausea, vomiting and fever (not involving hospitalisation)fever (not involving hospitalisation)Less common: need for additional surgery; premature ovarian failure particularly in women over 45 Less common: need for additional surgery; premature ovarian failure particularly in women over 45 years old; haematomayears old; haematomaRare: haemorrhage; non-target embolisation causing tissue necrosis; infection causing septicaemiaRare: haemorrhage; non-target embolisation causing tissue necrosis; infection causing septicaemia

Unwanted Effects of TreatmentsUnwanted Effects of TreatmentsMyomectomyMyomectomy Less common: Less common: adhesions (which may lead to pain and/or impaired fertility); adhesions (which may lead to pain and/or impaired fertility); need for additional need for additional

surgery; recurrence of fibroids; perforation (hysteroscopic route); infectionsurgery; recurrence of fibroids; perforation (hysteroscopic route); infectionRare: Rare: haemorrhagehaemorrhage

HysterectomyHysterectomy Common: Common: infectioninfectionLess common: intraoperative haemorrhage; Less common: intraoperative haemorrhage; damage to other abdominal organs, such as the urinary damage to other abdominal organs, such as the urinary tract or bowel; tract or bowel; urinary dysfunction – frequent passing of urine and incontinenceurinary dysfunction – frequent passing of urine and incontinenceRare: thrombosis (DVT and clot on the lung)Rare: thrombosis (DVT and clot on the lung)Very rare: deathVery rare: death(Complications are more likely when hysterectomy is performed in the presence of fibroids.)(Complications are more likely when hysterectomy is performed in the presence of fibroids.)

Oophorectomy at time of Oophorectomy at time of hysterectomyhysterectomy

Common: Common: menopausal-like symptomsmenopausal-like symptoms